A nurse is assisting with the care of a client who has pneumonia.
For each potential nursing action, click to specify if the potential action is anticipated or contraindicated for the client.
Apply a cool compress to the extremity.
Assist in inserting a new IV catheter in a site distal to infiltration site.
Elevate extremity.
Administer phytonadione.
Send the catheter tip for culture.
Suggest irrigating the IV catheter.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"B"}}
Anticipated:
- Apply a cool compress to the extremity. A cool compress can reduce swelling, relieve discomfort, and help minimize the tightness in the skin caused by edema. The cold temperature helps constrict blood vessels, reducing fluid buildup in the tissues. This intervention is appropriate for managing IV infiltration-related symptoms.
- Assist in inserting a new IV catheter in a site distal to the infiltration site. If the IV site becomes infiltrated, the correct approach is to stop the current infusion and insert a new catheter in a different location, preferably distal to the infiltration site. This ensures continued IV access without further aggravating the infiltrated site.
- Elevate extremity. Elevating the affected extremity can help reduce swelling by promoting venous return. Elevation improves circulation and decreases the pressure caused by fluid accumulation in the tissues. This is an effective intervention for managing swelling in the right upper extremity due to infiltration.
Not Anticipated:
- Phytonadione (vitamin K) is typically used to reverse the effects of anticoagulation medications or treat vitamin K deficiency. This is not indicated for the client, as there is no evidence of bleeding or an anticoagulation issue that requires vitamin K. The client's current problem is an IV infiltration, not a clotting disorder.
- Send the catheter tip for culture. At this point, there are no signs of infection such as redness, warmth, or discharge from the IV site. The primary concern is managing the infiltration, so sending the catheter tip for culture is unnecessary unless infection is suspected. Culture collection is reserved for cases where an infection is present.
- Suggest irrigating the IV catheter. Irrigating an infiltrated IV catheter could worsen the situation by pushing fluids further into the surrounding tissue or introducing bacteria. The proper action is to discontinue the infusion, remove the IV, and insert a new catheter at a different site rather than attempting to irrigate an already compromised catheter.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Drain the tub water before the client gets out. Draining the tub water before the client gets out is not a recommended practice. Instead, the nurse should ensure that the client has a safe way to exit the tub while the water is still in it, as the water can provide support and stability when getting out.
B. Add bath oil to the water after the client gets into the tub. Adding bath oil to the water can create a slippery surface, increasing the risk of falls and injury. It is best to avoid bath oils, especially for clients who may have mobility issues or are at risk for falls.
C. Allow the client to remain in the bath for 30 min. While soaking in a tub can be relaxing, staying in the bath for too long can increase the risk of overheating or dehydration. A shorter duration may be more appropriate, depending on the client's condition and safety.
D. Check on the client every 10 min during the bath. Checking on the client regularly during the bath is essential for ensuring their safety. This practice allows the nurse to monitor for any signs of distress, difficulty, or the need for assistance, providing reassurance and promoting the client's well-being.
Correct Answer is D
Explanation
A. "Position the car seat at a 90° angle." Positioning the car seat at a 90° angle is not recommended. The car seat should be reclined at an angle of 30 to 45 degrees to ensure that the infant's head does not flop forward, which can obstruct the airway.
B. "Keep the airbag on if the car seat is in the front seat." Keeping the airbag on when a car seat is in the front seat is unsafe. It is recommended to place the car seat in the back seat, as the force of an airbag deploying can be harmful to a child in a car seat.
C. "Put a small cushion under the newborn's head for support." Placing a cushion under the newborn's head is not recommended, as it can interfere with the proper positioning of the car seat and compromise the safety of the infant. The car seat is designed to provide support without additional cushions.
D. "Place the shoulder harnesses at the level of the infant's shoulders." Placing the shoulder harnesses at the level of the infant's shoulders is the correct practice. The harnesses should be positioned snugly at or just above the shoulders for optimal safety, ensuring that the infant is securely restrained in the car seat.
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